Thoracoscopic enucleation of esophageal leiomyoma in semi-prone position: how I do it

Introduction

The most common type of esophageal benign tumor is leiomyoma, accounting for 70–80% (1). Ever since the first removal of tumors via thoracoscopy in 1992, this method became the procedure of choice for the surgeons.

Thoracoscopic enucleation reduces damage, discomfort, and complications for patients compared to open surgery. The minimally invasive intervention allows shorter duration of hospital stay and quicker post-surgery recovery (2-5).

Previously, the indication for thoracoscopic enucleation was only applied to tumors between 2 to 5 cm in diameter. However, when minimally invasive surgery became popular and surgeons have gained more experience, the indications have been expanded. Recently, thoracoscopic enucleation is the first choice in the treatment of esophageal leiomyoma, in which surgeon experience is a prerequisite factor, and large tumor size or tumor morphology complexity is not an absolute contraindication (6,7). Right thoracoscopy is the preferred approach for tumors located in two upper thirds of the esophagus. Left thoracoscopy is indicated for esophageal leiomyoma on the rest of the esophagus, and the semi-prone position is widely used due to its many advantages (8,9). Technically, the authors have proposed many different options to help make surgery safe and effective.

From 2005, we have performed over 100 thoracoscopic enucleation of esophageal leiomyoma, in which the semi-prone position is used in about 90% of cases with good results: rate of mucosal injuries during operation was less than 10%, no postoperative leaks or major complication after surgery. We would like to present some experiences about this surgery, to make surgery more convenient and safer. The article was written in accordance with the SUPER reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-22-66/rc).

Preoperative preparations and requirements

Surgical indication: symptomatic esophageal leiomyoma or tumor size over 2 cm (in endoscopic ultrasound). All patients undergo preoperative assessments and tests, which consist of esophagogastroduodenoscopy, esophagography, chest computed tomography, esophageal endoscopic ultrasonography, complete blood count tests, pulmonary function tests, and cardiovascular tests. The operation was performed by digestive surgeons , at VIET DUC Hospital (a special grade surgical hospital in Vietnam).

All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The patient has given consent for the recording and publication of the images and video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Patient position

After general anesthesia induction and selective endotracheal intubation, the patient is positioned semi-prone with 30° rotation (Figure 1). This position has many advantages: no need for retractorss to lift the lungs, limited blood and fluid accumulation in the surgical field, and especially the surgical field is spacious and easy to manipulate.

Figure 1 Semi-prone position with 30° rotation.

For tumors located in the upper and middle thirds of the thoracic esophagus: the entrance is through the right chest, for tumor in the lower third, the entrance is through the left chest. However, recently we have used the right thoracic approach for all esophageal tumor locations, and have had good results (in cases where the tumor grows towards the left esophageal wall, we release the esophagus and lift the esophagus with a mesh, to perform surgery). We use single-lung ventilation in all cases, and pneumothorax is created with CO₂ pressure of 8 to 10 mmHg. In some cases, the tumor is located below the azygos vein; here we ligate and divide the vein to expose the tumor.

Trocar placement

Three 10 mm trocars are inserted: the camera port is in the 7^th intercostal space of posterior axillary line. Two instrument port is in the 5^th and 7^th intercostal space on mid axillary line. However, the position of the trocars can vary according to the tumor location in the esophagus, and in difficult cases, a fourth trocar can be necessary (Figure 2).

Figure 2 Variation in position and number of trocarts. (A) Tumor enucleation with 3 trocarts. (B) For large tumors, tumors with complex shapes, 4 trocarts can be used.

The five steps of thoracoscopic enucleation of esophageal leiomyoma (Video 1)

• Step 1: tumor location: the lesion is usually easily located by direct vision and palpation. If the surgeon cannot identify the tumor, the esophagus should be dissected or a flexible esophagoscope should be placed adjacent to the tumor to demarcate its location. In some situations, a 54 F bougie can be placed to landmark the location of the tumor and assist dissection (10-12).
• Step 2: myotomy: a longitudinal incision is performed and the muscle edges are carefully preserved for subsequent closure to prevent the onset of pseudodiverticulum. In the case of large tumors, especially giant tumors, the muscle layer above the tumor is often thinly hypoplastic, or absent. In this situation, weperform an oval muscle opening around the tumor base to remove both the tumor and the hypoplastic muscle and obtain healthy segments of the esophagus. Attention should be paid to conserve the main vagal trunks.
• Step 3: tumor ablation:the tumor is enucleated from the muscularis propria of the esophagus by electric hook, it is helpful to place a retracting suture through the tumor (with Vicryl 2.0). By holding this suture, one can lift the tumor up and find the suitable separation plane (Figure 3). In the case of a large tumor or multilobular tumor, it is possible to place multiple retracting sutures at different poles of the tumor and lift the tumor during surgery. This procedure clearly defines the dissecting layer and avoids damaging of esophagial mucosa. The tumor is excised and taken out with a specimen bag (9,10).
  

  Figure 3 Tumor ablation.
• Step 4: mucosal integrity testing: once the tumor has been removed, intraoperative esophagogastroscopy is performed to inspect for injury of the esophageal mucosa. The esophagus is submerged with 0.9% saline, and air is inflated into the lumen, making the mucosa bulge at the surgery site (Figure 4). This allows surgeons to identify any perforation. Mucosal leak is infrequent, but intraoperative evaluation is mandatory and, when any interruption is recognized, almost all mucosal perforations can be close with interrupted 5.0 polydioxanone (PDS) (4,9,10).
  

  Figure 4 Mucosal integrity testing.
• Step 5: the myotomy is then sutured with interrupted 2-0 absorbable, attention paid to take full-thickness bites of the muscularis propria. A chest tube is then placed systematically posterior to the lung.

Postoperative considerations and tasks

After surgery, the patient is transferred to the inpatient department, without needing intensive care unit (ICU). The nasogastric tube is removed on the third day after a normal esophagography, the chest tube is removed immediately afterward, except for patients with mucosal injury for whom the tube is removed on the 7^th day after the surgery. The patient is fed after the nasogastric tube is removed.

Patients were re-examined after 3 months and then annually to evaluate postoperative complications as well as tumor recurrence. We routinely perform esophagography and esophagogastroduodenoscopy at 1 year after the operation.

Tips and pearls

• Preoperative tumor biopsy through gastroesophageal endoscopy is not recommended because it will cause adhesion of the esophageal mucosa to the tumor, which can easily cause mucosal damage during operation.
• The location of the trocars can vary depending on the tumor location.
• In the case of tumors in the upper third of the esophagus, the azygos vein can be divided to enlarge the surgical field.
• Right thoracoscopy can be performed for leiomyoma of the lower part of the esophagus.
• In cases where the tumor is smaller than 2 cm, it is often difficult to locate the tumor during operation. If necessary, a flexible esophagoscopy can be used to find the tumor.

Discussion

The left lateral position was used for the initial thoracoscopic enucleation of esophageal leiomyoma by Everitt in 1992 (3). This position was employed by several other teams for video-assisted thoracoscopic surgery (VATS) (7,11,13). The advantages of the left lateral position are that it creates a surgical field similar to thoracotomy and is ideal in case thoracotomy is required. Limitations include difficulty in accessing the posterior mediastinum, blood accumulation in the surgical area in case of bleeding, need for an additional port for lung retraction.

The prone position has also been used by some authors (14,15). The advantage of the prone position is easy access to the mediastinum, especially the posterior mediastinum. However, it is very difficult in cases where thoracotomy is needed.

In 2007, Pawar recommended the semi-prone position touting advantages such as no need for retractors to lift the lungs, limited blood and fluid accumulation in the surgical field, spacious surgical field and ease of manipulation (16). We have used the semi-prone position for thoracoscopic enucleation of esophageal leiomyoma with the since 2006, with good results. We agree with Pawar et al. (16) and Lin et al. (17) that the semi-prone position combines the advantages and limits the disadvantages of the prone and the lateral positions, making surgery more convenient.

With respect to the operative technique, after visualization of the lesion via thoracoscopy or transillumination through endoscopy, in agreement with most authors (6-8,11,12) the essential steps of our tumor enucleation technique includes longitudinal incision of the mediastinal pleura over the tumor by an endoscopic hook electrocauterizer, circumferential mobilization of the esophagus to facilitate exposure while avoiding injuring the vagus nerve, longitudinal incision of the overlying muscle, placement of stay sutures on the mass and then meticulous dissection of the plane between the mass and the submucosal layer. Mucosa integrity should be checked looking for bubbles after insufflating air through the nasogastric tube with the esophagus submerged in saline. The muscle layer is then reapproximated and a 28 or 32 Fr chest tube is inserted.

In patients with large tumors, especially giant tumors, the muscle layer covering the tumor is often thin, hypoplastic, or absent. In this setting, we prefer an oval myotomy around the tumor base to remove both the tumor and the overlying hypoplastic muscle to retain only the healthy muscle of esophagus rather than a longitudinal myotomy. This procedure reduces operation time as it removes the hypoplastic esophageal muscle, the muscular suture is stronger. Additionally, for these large or multilobular tumors, we place several stay sutures on the different protusions thus facilitating dissection and avoiding mucosal injury.

Conclusions

Thoracoscopic enucleation of esophageal leiomyoma is safe and effective; the semi-prone position facilitates the surgery. Depending on the location, size, and morphology of the tumor, the operative technique needs to be adjusted to render surgery more effective.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery for the series “The Expert’s Technical Corner: How I Do It”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-22-66/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-22-66/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-22-66/coif). The series “The Expert’s Technical Corner: How I Do It” was commissioned by the editorial office without any funding or sponsorship. A.F. served as the unpaid Guest Editor of the series and serves as the co-Editor-in-Chief of Annals of Laparoscopic and Endoscopic Surgery from April 2016 to April 2026. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The patient has given consent for the recording and publication of the images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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